Claims adjudication refers to a process of paying claims submitted by a person or denying them after comparing the claims with benefits and coverage details indicated in a policy. Currently, implementation of claims adjudication requires manual development of process maps from policies and generation of rules based on translating natural language content of the policies into a plurality of rules. The claims are then adjudicated based on the process maps and the rules.
Regulations and guidelines as in how to adjudicate claims are constantly evolving. Further, policies may continuously be updated by payers or contracts between the payers and providers may continuously be revised. Accordingly, frequent changes in the policies would require complete rewrite of the rules. Consequently, such claims adjudication may be labor intensive, costly, time consuming, and error prone. A technical problem that arises in adjudicating claims using current systems is that the current systems are unable to react quickly to changes in policies to ensure efficient and timely claim adjudication. The present disclosure provides a technical solution to the problem that accounts for changes in policies in real time to create new or modified rules that may be used by for automatic claim adjudication.